Identification of Legionella feeleii Cellulitis

To the Editor: In general, reports of extrapulmonary Legionella spp. infections are scarce. For example, L. micdadei infection was found with the following manifestations: a mass on the left side of the neck and low-grade fever in a healthy 9-year-old girl (1); multiple liver and lung abscesses in a 7-year-old girl with acute lymphoblas-tic leukemia who had undergone allo-geneic cord blood transplantation (2); and a cerebral abscess in a patient with legionellosis (3). L. feeleii was fi rst described in 1984 as the causative agent of a Pon-tiac fever outbreak (4). L. feeleii was responsible, according to a recent review , for only 10 reported cases of infections, all of which were pneumonia , only 1 complicated by endocardi-tis (5). Unlike lung abscesses, cutane-ous lesions caused by Legionella spp. are uncommon. Recurrent soft tissue abscesses of the jaw, wrist, and arm caused by L. cincinnatiensis were described in a 73-year-old woman with nephrotic syndrome and idiopathic immunoglobulin gammopathy (6). L. micdadei has been found in a cutane-ous abscess of the leg of a 62-year-old immunosuppressed woman, and it was responsible for necrotizing cellulitis that resulted in amputation of the left arm of a recipient of a cadaveric renal transplant (7). L. pneumophila with mixed fl ora was identifi ed in a peri-rectal abscess (8) and in skin samples from a patient with lymphoma and cel-lulitis associated with pneumonia (9). The infrequency of reporting Legio-nella spp. cutaneous infections may be explained in part by the fact that Legionella spp. agar is not routinely a part of media inoculated for cases of cutaneous abscess. Here we report the identifi cation of L. feeleii in a cutane-ous infection through the use of a shell vial culture protocol. In late October 2009, a 66-year-old woman was admitted to Hôpital Nord, Marseille, France, for a papular lesion complicated by cellulitis and an abscess, centered on her right leg (Figure). The patient's history noted that she had been bitten by an insect or spider (suspected to be a spider) on October 9. The next day, the patient had a fever of 39°C, and a papular le-sion appeared around the bite. Four days later, the fever had persisted, and she was given amoxicillin-clavulanate and local wound care. Two days later, the lesion became necrotic, and levo-fl oxacin was added to the medication regimen. At day 10 after the bite, cel-lulitis with a central abscess appeared on her …